Alameda County Emergency Medical Services Quality Improvement Program Plan 9/21//2017

Transcription

1 Alameda County Emergency Medical Services Quality Improvement Program Plan 9/21//2017 California Code of Regulations TITLE 22. SOCIAL SECURITY DIVISION 9. PRE-HOSPITAL EMERGENCY MEDICAL SERVICES CHAPTER 12. EMS System Quality Improvement The URL for the EMS Quality Improvement Program (EQIP) Template from EMSAAC is: Page 1

2 Table of Contents Page I. Mission - Vision - Values 3 II. Structure, Organizational Description, Responsibilities 5 III. Data Collection, Evaluation of, Reporting 20 IV. Action to Improve 35 V. Training and Education 42 VI. Annual Update 44 Introduction The Alameda County EMS Agency is a patient centered Local Emergency Medical Services Agency. With this patient centered perspective, Alameda County EMS understands that the practice of medicine is dynamic. We are committed to adapting the service we provide to our continually changing community. We believe in continuous education and Quality Improvement of ourselves, our providers and our community. Input from field providers and the public we serve is essential in developing and improving this plan. From The Institute of Medicine, Alameda County EMS has adopted a shared vision of six specific aims for Quality Improvement. These aims are built around the core need for health care to be: Safe: Avoiding injuries to patients from the care that is intended to help them Effective: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status Page 2

3 About This Plan This plan is a guideline for each Alameda County EMS provider s Quality Improvement (QI) Plan. Each EMS provider is required to submit its QI Plan to the EMS Agency for review and approval. All pragmatic improvement plans, and each improvement activity within the plan, work best when they are simple and focused. The Alameda County EMS Quality Improvement Plan integrates Quality Improvement models from a wide variety of sources including Results Based Accountability, Baldrige, Deming and Six Sigma. While these Quality Improvement models, on the surface, seem to vary in their methodologies, they all focus on answering fundamental questions. (Mike Taigman) This Quality Improvement Plan is structured to answer 5 fundamental questions: Why do we do what we do? How do we see ourselves in the future? What governs our day to day decisions? How are we doing? What are we doing to make things better? I. Alameda County EMS Mission Vision Values Mission Why do we do what we do? The Alameda County EMS mission is to ensure the provision of quality emergency medical services and prevention programs to improve health and safety in Alameda County. Vision How do we see ourselves in the future? The Alameda County EMS vision is to explore new frontiers while creating an environment where collaboration and consensus building thrive among staff and stakeholders. We look to measurably reduce pain and suffering and improve the health of our patients. Page 3

4 Values What governs our day to day decisions? Alameda County EMS values a caring environment sustained by empowerment, honesty, integrity, and mutual respect. We embrace excellence through innovation, teamwork, and community capacity building. STARCARE is a values based checklist developed by paramedic author/ems educator Thom Dick. It has been adopted by the current largest ground transport provider in Alameda County, Paramedics Plus. STARCARE promotes a patient centered; values based culture as a guide for providers for decision making. Safe -- Were my actions safe for me, for my colleagues, for other professionals and for the public? Team-based -- Were my actions taken with due regard for the opinions and feelings of my co-workers, even those from other agencies? Attentive to human needs -- Did I treat my patient as a person? Did I keep him or her warm? Was I gentle? Did I use his or her name throughout the call? Did I tell him or her what to expect in advance? Did I treat his or her family and / or relatives with respect? Respectful -- Did I act toward my patient, my colleagues, my first responders, the hospital staff and the public with the kind of respect that I would have wanted to receive myself? Customer accountable -- If I were face-to-face right now with the customers I dealt with on this response, could I look them in the eye and say, I did my very best for you. Appropriate -- Was my care appropriate - medically, professionally, legally and practically, considering the circumstances I faced? Reasonable -- Did my actions make sense? Would a reasonable colleague of my experience have acted similarly under the same circumstances? Ethical -- Were my actions fair and honest in every way? Are my answers to these questions honest with integrity? Page 4

5 II. Structure, Organizational Description, Responsibilities Why do we do what we do? What are we doing to make things better? Alameda County Demographics Alameda County is both geographically and demographically diverse. The entire county covers 739 square miles and includes highly dense urban areas; the shoreline of San Francisco Bay is on the western border, low and high density residential areas, and a high concentration of industrial sites, and rural, wilderness and parks areas that stretch to the east. More than 1.6 million people live in Alameda County. The City of Oakland, in the north part of the County, is the largest city with a population of 412,000+. Other large cities include Fremont in the south (210,000+), the City of Hayward in the mid-part of the County (146,000+), and the City of Berkeley in the northern sector of the County (105,000+). Approximately 160,000+ people reside in the cities of Livermore, Dublin and Pleasanton that are located in eastern Alameda County. Page 5

6 EMS Overview The Alameda County EMS system responds to approximately 160,000 calls annually for medical emergencies. Generally a fire department unit and a Paramedics Plus ambulance responds to emergency medical calls. Alameda, Albany, Berkeley and Piedmont fire departments provide ambulance transport services in addition to first response. In the remaining areas of the county, fire departments respond with ALS fire units and Paramedics Plus provides emergency transport services under contract with the County. Below is a list of the EMS providers in Alameda County. EMS System Providers ALS Ground Transport Providers Alameda City Fire Department Albany Fire Department Berkeley Fire Department Piedmont Fire Department Paramedics Plus First Responder ALS (FRALS) Alameda County Fire Department Albany Fire Department Camp Parks Fire Department Berkeley Fire Department Piedmont Fire Department Fremont Fire Department Hayward Fire Department Livermore-Pleasanton Fire Department Oakland Fire Department East Bay Regional Parks Fire Department *ACFD at Livermore Lab transports patients from its facility with fewer than 100 responses Air Transport Providers REACH CALSTAR Lifeflight East Bay Regional Parks Interfacility Transport (IFT) Providers AMR Arcadia Bay Medic Bayshore Falck Falcon Norcal Pro Transport-1 Royal Westmed Receiving Facilities Alta Bates Hospital Summit Hospital Childrens Hospital Oakland Kaiser Oakland Hospital Alameda Hospital Alameda County Medical Center (Base Hospital) San Leandro Hospital John George Pavilion Willow Rock Eden Hospital Valley Care Hospital Kaiser San Leandro Hospital Kaiser Fremont Hospital Washington Hospital EMS System Partners Patients Patient Families The Community All Providers All Receiving Facilities County Board of Supervisors and City Councils Insurance companies and other third party payers Vendors Education/Training Organizations Other Regulatory Agencies Page 6

7 ORGANIZATIONAL STRUCTURE The EMS Agency is a division of the Alameda County Health Care Services Agency. The EMS Agency coordinates EMS activities in Alameda County. The Board of Supervisors (five members) makes general policy decisions affecting health care. The Director of the Health Care Services Agency reports to the Board of Supervisors. The EMS Director reports to the Health Care Services Agency Director. Medical control of the prehospital medical care within the system is the responsibility of the EMS Medical Director who reports to the EMS Director. Alameda County Board of Supervisors Health Care Services Agency Behavioral Health Public Health Environmental Health Emergency Medical Services Page 7

8 EMERGENCY MEDICAL SERVICES Page 8

9 QUALITY IMPROVEMENT RESPONSIBILITIES - GENERAL GUIDELINES 1. The EMS Agency shall establish and facilitate a system wide quality improvement program to monitor, review, evaluate and improve the delivery of prehospital care services. 1.1 The program shall involve all system participants and shall include, but not be limited to the following activities: Prospective - designed to prevent potential problems Concurrent - designed to identify problems or potential problems during the course of patient care Retrospective - designed to identify potential or known problems and prevent their recurrence Reporting/Feedback - all quality improvement activities will be reported to the EMS Agency in a manner to be jointly determined. As a result of Q.I./Q.A. activities, changes in system design may be made. 2. Each agency shall submit a Quality Improvement Plan, based on the appropriate policy to the EMS Agency for approval. The time frame for submission will be determined by the EMS Agency. 3. Appropriate revisions shall be made as requested by the EMS Agency. 4. Each agency shall conduct an annual review of their Q.I. plan. 5. The EMS Agency will evaluate the implementation of each agency's Q.I plan. Page 9

10 QUALITY IMPROVEMENT RESPONSIBILITIES - EMS Authority: Division 2.5 of the Health and Safety Code, Chapter Prospective 1.1 Comply with all pertinent rules, regulations, laws and codes of Federal, State and County applicable to emergency medical services. 1.2 Coordinate prehospital quality improvement committees. 1.3 Plan, implement and evaluate the emergency medical services system including public and private agreements and operational procedures. 1.4 Implement advanced life support systems and limited advanced life support systems 1.5 Approve and monitor prehospital training programs. 1.6 Certify/authorize prehospital personnel. 1.7 Establish policies and procedures to assure medical control and oversight, which may include dispatch, basic life support, advanced life support, patient destination, patient care guidelines and quality improvement requirements. 1.8 Facilitate implementation by system participants of required Quality Improvement plans. 1.9 Design reports for monitoring identified problems and/or trends analysis Approve standardized corrective action plan for identified deficiencies in prehospital and base hospital personnel. 2. Concurrent 2.1 Site visits to monitor and evaluate system components. 2.2 On call availability for unusual occurrences, including but not limited to: Multicasualty Incidents (MCI) Ambulance Rerouting and Hospital Bypass 2. Retrospective 3.1 Evaluate the process developed by system participants for retrospective analysis of prehospital care. 3.2 Evaluate identified trends in the quality of prehospital care delivered in the system. 3.3 Establish procedures for implementing the Certificate Review Process for prehospital emergency medical personnel. 3.4 Monitor and evaluate the Incident Review Process. 4. Reporting/Feedback 4.1 Evaluate submitted reports from system participants and make changes in system design as necessary. 4.2 Provide feedback to system participants when applicable or when requested on Quality Improvement issues. 4.3 Design prehospital research and efficacy studies regarding the prehospital use of any drug, device or treatment procedure where applicable. Page 10

11 QUALITY IMPROVEMENT RESPONSIBILITIES - DISPATCH 1. Prospective 1.1 Participation on committees as specified by the EMS Agency. 1.2 Education Orientation to the EMS system Continuing education activities to further the knowledge base of the dispatcher, to include but not limited to: Tape review Educational programs based on problem identification and trend analysis Discussion of selected calls Participation in certification and training of the EMD Establish procedure for informing all EMDs of system changes 1.3 Evaluation - Develop criteria for evaluation of individual EMDs to include, but not limited to: Tape review or other documentation as available Evaluation of new employees Routine Problem-oriented Design standardized corrective action plans for individual EMD deficiencies. 1.4 Certification Initial certification Recertification 2. Concurrent 2.1 Establish a procedure for evaluation of EMDs utilizing performance standards through direct observation 3. Retrospective Analysis 3.1 Develop a process for retrospective analysis of dispatched calls, utilizing audio tape and dispatcher report form, to include but not limited to: High-risk High-volume Problem oriented calls Any call requested to be reviewed by EMS or other appropriate agency Specific audit topics established through the Quality Improvement Committee. 3.2 Develop performance standards for evaluating the quality of care delivered by the EMD through retrospective analysis. 3.3 Participation in the incident review process 3.4 Comply with reporting and other quality improvement requirements as specified by the EMS Agency. 3.5 Participation in prehospital research and efficacy studies requested by the EMS Agency and/or the Quality Improvement Committee. 4. Reporting/Feedback 4.1 Develop a process for identifying trends in the quality of dispatch care Report as specified by the EMS Agency Design and participate in educational offerings based on problem identification and trend analysis Make approved changes in internal policies and procedures based on trend analysis Page 11

12 PSAP and Dispatch Call Handling Structure in Alameda County Call Location Primary PSAP Receive Call Fire 1 st Response Dispatch Ambulance Dispatch EMD* Provided By Alameda City Alameda Police PSAP Call transferred from PD PSAP to ACRECC who dispatches fire units/ambulances ACRECC dispatches city ambulances ACRECC Alameda County (and areas served by County Fire) County Sherriff (unincorporated and Dublin); San Leandro Police PSAP; Livermore Lab PSAP Calls transferred from various PD PSAPs to ACRECC who dispatches fire units Albany Albany Police PSAP Albany PD dispatches fire units Berkeley Camp Parks Emeryville Berkeley PD PSAP (dual police and fire) City of Dublin Police PSAP Emeryville Police PSAP Berkeley PD dispatches fire units Call transferred from Dublin PD PSAP to ACRECC who dispatches fire units Call transferred from Emeryville PD to ACRECC who dispatches fire units Fremont Fremont Police PSAP Call transferred from PD PSAP to ACRECC who dispatches fire units Hayward Hayward Police PSAP Hayward PD PSAP dispatches fire units and transfers call to ACRECC Livermore Livermore Police PSAP Call transferred from Livermore PD PSAP to ACRECC who dispatches fire units Pleasanton Pleasanton Police PSAP Call transferred from Pleasanton PD to ACRECC who dispatches fire units Newark Newark Police PSAP Call transferred from PD PSAP to ACRECC who dispatches fire units Oakland Oakland Police PSAP Call transferred from PD PSAP to Oakland Fire Dispatch who dispatches fire units Piedmont East Bay Regional Parks Union City Piedmont Police/Fire (joint PSAP) EBRP PSAP and dispatch Union City Police PSAP Piedmont PD/Fire dispatches fire and city ambulances EBRP dispatches Parks units and transfers call to ACRECC or to the transport city PSAPs Call transferred from PD PSAP to ACRECC who dispatches fire units ACRECC dispatches Paramedics Plus ambulances Albany PD dispatches city ambulances Berkeley PD dispatches city ambulances ACRECC dispatches Paramedics Plus ambulances ACRECC dispatches Paramedics Plus ambulances ACRECC dispatches Paramedics Plus ambulances ACRECC dispatches Paramedics Plus ambulances ACRECC dispatches Paramedic Plus ambulances ACRECC dispatches Paramedics Plus ambulances ACRECC dispatches Paramedics Plus ambulances Oakland Fire Dispatch transfers call to ACCREC who dispatches Paramedics Plus ambulances Piedmont PD/Fire PSAP ACRECC dispatches Paramedics Plus ambulances; local PSAPs dispatch fire units/ambulances ACRECC dispatches Paramedics Plus ambulances ACRECC None ACRECC ACRECC ACRECC ACRECC ACRECC ACRECC ACRECC ACRECC Oakland Fire Dispatch None ACRECC ACRECC Cellular Calls CA Highway Patrol Per response jurisdiction Varies by jurisdiction Varies by jurisdiction Page 12

13 QUALITY IMPROVEMENT RESPONSIBILITIES - ALS Provider Agencies 1. Prospective 1.1 Participation on committees as specified by the EMS Agency. 1.2 Education Orientation to EMS system Continuing Education Participate in certification courses and the training of prehospital care providers Offer educational programs based on problem identification and trend analysis Establish procedure for informing all field personnel of system changes 1.3 Evaluation - Develop criteria for evaluation of individual paramedics to include, but not limited to: PCR review/tape review or other documentation as available Ride-along Evaluation of new employees Routine Problem-oriented Design standardized corrective action plans for individual paramedic deficiencies 1.4 Certification/Accreditation - establish procedures, Based on Alameda County policies, regarding: Initial certification/accreditation Recertification/Continuing Accreditation ITLS, PHTLS or ATT certification ACLS, ECC certification PALS or PEPP Preceptor authorization Other training as specified by the EMS Agency. 2. Concurrent 2.1 Ride-along - Establish a procedure for evaluation of paramedics utilizing performance standards through direct observation 2.2 Provide availability of Field Supervisors and/or Quality Improvement Liaison personnel for consultation/assistance. 2.3 Provide patient information to the base hospital to facilitate obtaining patient follow-up information from receiving hospitals. 3. Retrospective Analysis 3.1 Develop a process for retrospective analysis of field care, utilizing PCRs and audio tape (if applicable), to include but not limited to: High-risk High-volume Problem-oriented calls Any call requested to be reviewed by EMS or other appropriate agency Specific audit topics established through the Quality Council. 3.2 Develop performance standards for evaluating the quality of care delivered by field personnel through retrospective analysis. 3.3 Participate in the Incident Review Process 3.4 Comply with reporting and other quality improvement requirements as specified by the EMS Agency. 3.5 Participate in prehospital research and efficacy studies requested by the EMS Agency and/or the Quality Improvement Committee Page 13

14 QUALITY IMPROVEMENT RESPONSIBILITIES - ALS Provider Agencies 4. Reporting/Feedback 4.1 Develop a process for identifying trends in the quality of field care Report as specified by the EMS Agency Design and participate in educational offering based on problem identification and trend analysis Make approved changes in internal policies and procedures based on trend analysis. QUALITY IMPROVEMENT RESPONSIBILITIES - EMS Aircraft Provider Agencies 1. Assign a liaison to interact with other EMS provider agencies, base hospital(s), and EMS Agency 2. Assure Agency s EMS personnel and pilots are currently and appropriately credentialed at all times 3. Assure Agency s personnel are fully oriented to EMS system prior to assigning to EMS response duties 3.1 Orientation to include pertinent policies, protocols, hospital locations, map reading, documentation requirements, etc. 3.2 Establish procedure for informing agency personnel of EMS system changes and updates 4. Provide the EMS Agency with clinical and response time data necessary for monitoring and evaluating the EMS system, particularly for trauma patients as part of the EMS trauma audit process 5. Participate in EMS Agency Quality Improvement activities Page 14

15 HOSPITAL RESPONSIBILITIES 1. A Receiving Hospital is a hospital designated as such by the Alameda County Health Officer and is licensed as a Basic Emergency Service or has in-house physician coverage 24 hours per day 2. A Receiving Hospital shall: 2.1 Accept all emergency patients transported by EMS system units unless ambulance diversion has been initiated in accordance with Alameda County Ambulance Diversion Policy and the facility's approved internal diversion protocol. 2.2 Admit emergency patients to the Hospital if appropriate, the patient accepts admission and the Hospital has space available. If transfer to another hospital is appropriate, the patient shall be transferred according to Alameda County Interfacility Transfer Guidelines. 2.3 Procure and maintain an operational radio for two way voice communication on the County MEDNET, meeting County specifications, and place this equipment in the emergency department. 2.4 Cooperate with the Alameda County Emergency Medical Services Agency and the Alameda County Health Care Services Agency in gathering and providing statistics and information needed for monitoring and evaluating prehospital programs. 2.5 Cooperate with designated Alameda County Base Hospitals and ALS Provider Agencies in providing follow-up information regarding patient diagnosis, disposition and outcome. 2.6 Follow and abide by the standards established for ALS programs and for Receiving Hospitals, including those standards pertaining to professional staffing. 2.7 Ensure that the emergency department staff and other appropriate hospital personnel possess sufficient skill and knowledge in field procedures that are continued within the emergency department. 2.8 Participate in the Receiving Hospital Committee and Trauma Audit Committee (TAC) meetings as requested. 2.9 Participate in training of prehospital personnel, in cooperation with and as coordinated by the EMS Agency Medical Director or designee Provide hospital census and bed availability information to the EMS agency through the Reddinet system daily by 7:00 a.m Participate in HAvBED drills/exercises as directed by the Alameda County EMS Agency. Page 15

16 QUALITY IMPROVEMENT RESPONSIBILITIES Base Hospital 1. An ALS Base Hospital is a hospital designated by the Alameda County Emergency Medical Services Agency and has: 1.1 A written contractual agreement with Alameda County 1.2 Primary responsibility for the direct, on line medical control of calls received from the field. 2. The Hospital shall agree to: 2.1 Utilize voice communications and be available to field personnel through a consistent channel, frequency, or telephone number twenty-four (24) hours a day, three hundred sixty-five (365) days a year. 2.2 Provide physician response within sixty (60) seconds of receipt of call. Physician orders and consultation shall be provided directly by the physician. 2.3 Initiate a Base Hospital Report Form completed by the Base Coordinator each time that the Base Hospital is contacted by an ALS unit with patient data. The document is a medical record, and as such, should meet criteria for all medical records, (e.g. must be in ink, be retained for seven (7) years, etc.). 2.4 The form must list all communications in chronological order by time and include a brief description of all communications received or transmitted. Each form shall include: Patient's run number Patient's chief complaint/problem Unit number The Base Hospital Physician Patient destination Pertinent comments 2.5 Record all communications between Base Hospital and ALS units Tape recordings are considered to be part of the patient's medical record and will be retained for a minimum of 100 days Tape recordings may be copied (in writing or by duplicating the tape) for teaching purposes. The patient's name should be omitted The Base Hospital shall provide a copy of any tape requested by the EMS Agency. 2.6 Abide by all standards, protocols, policies, procedures and contracts established by the County relating to prehospital ALS guidelines. Page 16

17 EMS Leadership/Quality Council (QC) The EMS Agency Director works with the EMS Medical Director, EMS QI Coordinator and the Quality Council to oversee the Alameda County EMS QI program. Quality Council Purpose: Serves as the Technical Advisory Group (TAG) for Alameda County EMS Identifies Quality Improvement needs Charter (and/or serve as) Quality Task Force(s) to improve system-wide processes (also known as Process Improvement Teams) Provides input for the EMS System Quality Improvement Plan Develops Quality Contributes to the development of a consistent approach to developing quality indicators and gathering and analyzing data Contributes to the development of a consistent approach to research Monitors and evaluates system data reports to identify opportunities for improvement and training needs Quality Council Membership: EMS Medical Director (Chair) EMS Director EMS Quality Improvement Coordinator EMS Quality Improvement Coordinators from each fire department Private 911 ambulance transport provider Quality Manager Base Hospital Paramedic Liaison Nurse One Paramedic and one EMT representing fire department in each of the North, South and East zones of Alameda County (6 total members) One Paramedic and one EMT from the 911 private medical transport provider agency One representative from an air transport provider Two representatives from Receiving Hospitals One representative each from OFD dispatch and ACCREC Quality Council Chairperson: EMS Medical Director Meetings: Monthly Two hours with a planned agenda Page 17

18 Committees Various committee collaborations are set up in specific areas of Quality Improvement focus. These committees have at least one EMS agency representative attending and preferably the EMS medical director in attendance EMS Quality Council - (See previous page) Emergency Medical Oversight Committee EMOC -The committee shall serve in an advisory capacity to, and report to, the Alameda County EMS Medical Director. The meetings are public and chaired by the EMS Medical Director. The committee is responsible for assisting in the development and/or implementation of: Medical policies or procedures Medical standards for prehospital care providers Quality improvement standards Receiving Hospital Committee STEMI Committee Stroke Committee Trauma Audit Committee Regional Trauma Committee Research Committee Equipment QI Committee - The committee reviews and makes recommendations for changes to the standardized supply list found in the field manual. The committee serves in an advisory capacity to, and reports to, the EMS Medical Director. The Procedures/Objectives of the Committee are : To only evaluate new equipment after study To evaluate for adoption new equipment after significant field input To evaluate new equipment using an objective format. (See: New Equipment Evaluation Form) Data Steering Committee epcr Change Committee Preceptor Committee EMS Section Chiefs Committee Alameda County Fire Chiefs Association EMSAAC/EMDAAC LEMSA Coordinators Committee Various other ad-hoc committees Page 18

19 ALAMEDA COUNTY EMERGENCY MEDICAL SERVICES AGENCY NEW PRODUCT EVALUATION FORM Product Evaluated: Date: Evaluated by: Type of Incident: Run #/PCR #: Describe how you used the product: Describe any problems associated with using the product: none What was the outcome of the product use? Describe what you liked about the product: Describe what you didn t like about the product: How many times have you used this product in the past day? week? Do you think this product would improve patient care or make your job easier or better? yes no why? Crew members (print names) Your unit #: Additional Comments: Page 19

20 III. Data Collection, Evaluation of and Reporting How are we doing? MEASURE IMPROVE, MEASURE IMPROVE, MEASURE IMPROVE.. Mickey Eisenberg, MD Various data systems in the Alameda County EMS system, including CAD, ZOLL epcr, Reddinet, and First Watch, contain relevant data. Electronic PCR data elements are NEMSIS 3.4 compliant. The implementation of all these data systems into user friendly data entry and reporting formats is essential to ensure that clean usable data is obtained. Integration of these data systems between dispatch, EMS providers, receiving facilities and state and national data systems is essential in opening up communication necessary to facilitating Quality Improvement. These data systems are used to: Prospectively identify areas for improvement and enable data driven decisions Monitor system changes after QI interventions have been implemented Monitor individual and group performance in the EMS system Support research Provide benchmarks with other EMS systems Data Quality Improvement activities include: Implementation of a user friendly Zoll epcr program for all 911 providers Implementation of a user friendly data reporting tool - Tableau Integration and continuing maintenance of all data systems Establishing health information bi-direction exchanges with receiving facilities and public health- All specialty receiving facility MOUs include language requiring participation in a bidirectional data exchange. EMS Provider Quality and Fitch Consultant Report, Alameda County, California, EMS System Review, January 31, 2008 Alameda County EMS engaged Fitch & Associates to conduct a review of the Alameda County EMS system and make recommendations for system design improvements. Many of those recommendations for Provider Quality and, with some updates, are listed in the next table. While the EMS Agency is responsible for creating and coordinating the overall Quality Improvement Plan for the EMS system, each EMS provider agency involved is responsible for developing their own EMS QI plan to monitor internal quality indicators and perform quality improvement activities. While quality improvement procedures for clinical aspects of the organization are important, they are not exclusive. The EMS agency should also include quality improvement activities and measures for all aspects of the organization as it relates to EMS. It would be overwhelming to attempt to list each activity and quality indicator that each system provider was responsible for accomplishing to maintain its ability to provide quality service to the EMS system users. The next table lists core quality activities and quality indicators for PSAPs, Dispatch, First Responders, Transport Agencies and Receiving Hospitals. These core activities and quality indicators are to be used as guidelines for specific EMS providers. Input from EMS providers comes to EMS through the Quality Council and other forums in determining the specific indicators and activities necessary in assessing, monitoring and improving the quality of the EMS system. It is important to note that the purpose of Quality and is to turn up the volume on the things the EMS system is doing well as well as identify processes that require improvement. The focus of EMS performance improvement is non-punitive Page 20

21 Summary of Provider Quality and PSAPs Dispatch Centers First Responders Ambulance Services Workload Management Matching schedules to demand Resource deployment practices Risk Management Employee welfare Workload Management Employee Satisfaction Employee Turnover Rate Maintaining and upgrading equipment and information systems Inventory Control Sharing of Resources Provider surveys/feedback Ease of use Resources involved in personnel skills training Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables Equipment durability/failures Workload Management Matching schedules to demand Resource deployment practices Risk Management Employee welfare Workload Management Employee Satisfaction Employee Turnover Rate Maintaining and upgrading equipment and information systems Inventory Control Sharing of Resources Provider surveys/feedback Ease of use Resources involved in personnel skills training Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables Equipment durability/failures Personnel/Resource Management Workload Management Matching schedules to demand Resource deployment practices Risk Management Employee welfare Workload Management Employee Satisfaction Employee Turnover Rate Equipment/Supplies Maintaining and upgrading equipment and information systems Inventory Control Sharing of Resources The effect of the equipment on patient pain/suffering and outcome Patient surveys/feedback Provider surveys/feedback Ease of use Resources involved in personnel skills training Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables Equipment durability/failures Workload Management Matching schedules to demand Resource deployment practices Risk Management Employee welfare Workload Management Employee Satisfaction Employee Turnover Rate Maintaining and upgrading equipment and information systems Inventory Control Sharing of Resources The effect of the equipment on patient pain/suffering and outcome Patient surveys/feedback Provider surveys/feedback Ease of use Resources involved in personnel skills training Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables Equipment durability/failures Receiving Hospitals Workload Management Matching schedules to demand Resource deployment practices Risk Management Employee welfare Workload Management Employee Satisfaction Employee Turnover Rate Maintaining and upgrading equipment and information systems Inventory Control Sharing of Resources The effect of the equipment on patient pain/suffering and outcome Patient surveys/feedback Provider surveys/feedback Ease of use Resources involved in personnel skills training Resources involved equipment acquisition, associated equipment costs, maintenance, resupply and consumables Equipment durability/failures Integration of Data Systems and Reporting Integration of Data Systems and Reporting Documentation Integration of Data Systems and Reporting Documentation reviews (especially non-transports, critical patients, under-triages) PCR data field compliance PCR Printing compliance Integration of Data Systems and Reporting Documentation reviews (especially non-transports, critical patients, undertriages) PCR data field compliance PCR Printing compliance Integration of Data Systems and Reporting Documentation reviews (especially non-transports, critical patients, undertriages) PCR data field compliance PCR Printing compliance Page 21

22 PSAPs Dispatch Centers First Responders Ambulance Services Training link to QI Unusual occurrence investigations Error Management Error reporting system (including self-reporting) Correct assignment of resources Call Reviews Peer Reviews Training link to QI Unusual occurrence investigations Error Management Error reporting system (including self-reporting) Correct assignment of resources Call Reviews Peer Reviews Operations/Clinical Care/Patient Outcome Training link to QI Unusual occurrence investigations Error Management Error reporting system (including self-reporting) Correct assignment of resources Call Reviews Peer Reviews Training link to QI Unusual occurrence investigations Error Management Error reporting system (including self-reporting) Correct assignment of resources Call Reviews Peer Reviews Receiving Hospitals Training link to QI Unusual occurrence investigations Error Management Error reporting system (including self-reporting) Correct assignment of resources Call Reviews Peer Reviews Time increments Call volume Calls per call taker Correct prioritization Accuracy of location identification Correct provision of prearrival instructions Correct transfer Time of day distribution Equipment failures Unusual occurrence tracking Complaint and Commendation tracking Time increments Call volume Calls per call taker Correct prioritization Categorization accuracy Correct patient condition code Accuracy of location identification Correct provision of prearrival instructions EMD compliance Correct transfer Time of day distribution Equipment failures Unusual occurrence tracking Complaint and Commendation tracking Tracking critical procedures Pain reduction Patient centered outcomes and changes Patient satisfaction surveys Verifiable and accurate data collection Over triage/undertriage Unusual occurrence tracking Complaint and Commendation tracking Tracking critical procedures Pain reduction Patient centered outcomes and changes Patient satisfaction surveys Verifiable and accurate data collection Over triage/undertriage Unusual occurrences Complaints and Commendations Patient diagnosis Pain reduction Time to definitive treatment Pt length of stay Pt morbidity/mortality Verifiable and accurate data collection Over triage/undertriage Unusual occurrence tracking Complaints and Commendations Training link to QI Continuing education Skills competencies New procedures and technology Emergency Medical Dispatch training and continuing ed. Field Training/Evaluations Mass casualty/disaster drills Research Studies Training link to QI Continuing education Skills competencies New procedures and technology Emergency Medical Dispatch training and continuing ed. Field Training/Evaluations Mass casualty/disaster drills Research Studies Education and Skills Competency Training linked to Quality Improvement findings Continuing education New procedures and technology Skill competencies Recertification Driver training Mass casualty/disaster drills Annual EMS training requirements Protocol Development Field Training/Evaluations Research Studies Establish patient outcome feedback loop to field providers Training linked to Quality Improvement findings Continuing education New procedures and technology Skill competencies Recertification Driver training Mass casualty/disaster drills Annual EMS training requirements Protocol Development Field Training/Evaluations Research Studies Establish patient outcome feedback loop to field providers Training linked to Quality Improvement findings Continuing education New procedures and technology Skill competencies Recertification Mass casualty/disaster drills Protocol Development Field Training/Evaluations Research Studies Establish patient outcome feedback loop to field providers Skills performance measures Skills performance measures Skills performance measures Skills performance measures Skills performance measures Page 22

23 PSAPs Dispatch Centers First Responders Ambulance Services Facility management Disaster Resources/Caches Community CPR AED Programs Bay Area Journal Club Disaster Preparedness Injury Prevention Specialized safety and risk training CAL OSHA training and policy compliance Unusual Occurrence investigations Patient/Customer complaint Investigations Facility management Disaster Resources/Caches Specialized safety and risk training CAL OSHA training and policy compliance Unusual Occurrence investigations Patient/Customer complaint investigations Transport/Facilities Fleet management Facility management Resource deployment practices Disaster Resources/Caches Response times Call time increments Time on task Call volume Mutual aid requests Accident rates Vehicle/equipment failure rates Simultaneous demand Public Education and Prevention First Aid When to call 911 Vials of Life type programs Referrals to other social and health care services (211) Risk Management Specialized safety and risk training CAL OSHA training and policy compliance Unusual Occurrence investigations Patient/Customer complaint investigations Fleet management Facility management Resource deployment practices Disaster Resources/Caches Response times Call time increments Time on task Call volume Mutual aid requests Accident rates Vehicle/equipment failure rates Simultaneous demand Receiving Hospitals Facility management Disaster Resources/Caches Reddinet Updates Number and distribution of base contacts Time to answer communications from field Quantity of patients received Frequency and duration of diversion Number of patients received at wrong facility Quantity of secondary transfers Wait Times (drop times) End of Life Care., POLST, Hospice Neighborhood Safety Violence Prevention Illness Prevention Stroke/Cardiac Specialized safety and risk training CAL OSHA training and policy compliance Unusual Occurrence investigations Patient/Customer complaint investigations Specialized safety and risk training CAL OSHA training and policy compliance Unusual Occurrence investigations Patient/Customer complaint investigations Illness/Injury rates and their severity Unusual Occurrence tracking including near misses Periodic and consistent reporting to policymakers and governing entity Timely, accurate, and complete data and information delivered to County EMS Agency Open Communication Development of an Non- Punitive Error Reporting Process Illness/Injury rates and their severity Unusual Occurrence tracking including near misses Periodic and consistent reporting to policymakers and governing entity Timely, accurate, and complete data and information delivered to County EMS Agency Open Communication Development of an Non- Punitive Error Reporting Process Illness/Injury/Exposure rates and their severity Vehicle accident rate Near misses Unusual Occurrence tracking including near misses Patient/Customer complaint tracking Medication/Treatment error identification and tracking Transparency Periodic and consistent reporting to policymakers and governing entity Timely, accurate, and complete data and information delivered to County EMS Agency Open Communication Development of an Non-Punitive Error Reporting Process Illness/Injury/Exposure rates and their severity Vehicle accident rate Unusual Occurrence tracking including near misses Patient/Customer complaint tracking Medication/Treatment error identification and tracking Periodic and consistent reporting to policymakers and governing entity Timely, accurate, and complete data and information delivered to County EMS Agency Open Communication Development of an Non- Punitive Error Reporting Process Illness/Injury/Exposure rates and their severity Unusual Occurrence tracking including near misses Patient/Customer complaint tracking Medication/Treatment error identification and tracking Periodic and consistent reporting to policymakers and governing entity Timely, accurate, and complete data and information delivered to County EMS Agency Open Communication Development of an Non- Punitive Error Reporting Process Page 23

24 Developing Specific Quality Structure + Process ~ Outcome If you don t measure, you don t know. Three Quality Indicator Attributes: Structure Things in the system (# of paramedics per population, # of ambulances, resources) Process or procedures (Response times, % of pts with pain > 7 receiving Fentanyl) Outcome Effects (% of cardiac arrest patients that survive to hospital discharge) RESULTS BASED ACCOUNTABILITY (RBA) Mark Friedman - Trying Hard Is Not Good Enough: How to Produce Measurable Improvements for Customers and Communities RBA uses a practical model for developing meaningful performance measures (quality indicators) by asking 3 simple questions: How much do we do? Input resource components (such as leadership, workforce, suppliers, equipment, etc.) are measured. These are the least important performance measures but the easiest to obtain. These performance measures assess the quantity of effort we put in. How well do we do it? The efficiency of design and delivery of work processes, productivity and operational performance are measured. These performance measures assess the quality of effort we put in. Is anyone better off? The result or outcome of patient care, support services, and fulfillment of public responsibilities are measured. These are the most important performance measures and the most difficult to obtain. These performance measures assess the quality effect of our efforts. Page 24

25 Three Step Indicator Development Process: 1. Engage stakeholders and subject experts for consensus on where and how to get the data. 2. Identify the data sources and elements and then query the data. 3. Review the report and validate results. Determine best data display format. Bi-Variable Indicator Specification Sheet Performance Measure (Indicator) ID Performance Measure (Indicator) Name Description Type of Measure Reporting Value Units Denominator Statement (population) Denominator Inclusion Criteria Criteria Data Elements Numerator Statement (sub-population) Numerator Inclusion Criteria Criteria Data Elements Exclusion Criteria Criteria Data Elements Indicator Formula Numeric Expression Example of Final Reporting Value (number and units) Benchmarks References For more on Quality Indicator Development and Use: Developing and Using Quality for EMS Evaluations and Improvement Craig Stroup Page 25

26 California EMS System Core Measures The purpose of the EMS system core measures project is to increase the accessibility and accuracy of pre-hospital data for public, policy, academic and research purposes to facilitate EMS system evaluation and improvement. Ultimately, the project highlights opportunities to improve the quality of patient care delivered within an EMS system. Alameda County EMS reports core measures yearly to state the Emergency Medical Services Authority. Each Alameda County EMS provider can track core measure data real time using Tableau Reporting. CCR Title 22, Div 9, Chap SET NAME SET ID PERFORMANCE MEASURE NAME Trauma (n=2) Acute Coronary Syndrome (n=4) TRA-1 TRA-2 ACS-1 ACS-2 ACS-3 ACS-5 Scene time for severely injured trauma patients Direct transport to trauma center for severely injured trauma patients meeting criteria Aspirin administration for chest pain/discomfort 12 lead ECG performance Scene time for suspected heart attack patients Direct transport to designated STEMI receiving center for suspected patients meeting criteria Clinical Care and Patient Outcome Cardiac Arrest CAR-2 Out-of-hospital cardiac arrests return of spontaneous circulation (n=3) Stroke (n=3) CAR-3 CAR-4 STR-2 Out-of-hospital cardiac arrests survival to emergency department discharge Out-of-hospital cardiac arrests survival to hospital discharge Glucose testing for suspected stroke patients STR-3 Scene time for suspected stroke patients STR-5 Direct transport to stroke center for suspected stroke patients meeting criteria Respiratory (n=1) Pediatric (n=1) RES-2 PED-1 Beta2 agonist administration for adults Pediatric asthma patients receiving bronchodilators Pain Intervention (n=1) PAI-1 Pain intervention Skills Maintenance and Competency Performance of Skills (n=2) SKL-1 SKL-2 Endotracheal intubation success rate End-Tidal CO2 performed on any successful endotracheal intubation Transportation and Facilities Response and Transport (n=3) RST-1 RST-2 RST-3 Ambulance response time by ambulance zone (Emergency) Ambulance response time by ambulance zone (Non-Emergency) Transport of patients to hospital Page 26

27 Alameda County Local Quality Multiple factors impact the validity and analysis of this data including: Data collection/measurement quality Random variances Patient population dynamics Clinical care quality * EMSA Core Measure ** Evidenced based performance measures recommended by the 2007 Consortium U.S. Metropolitan Municipalities EMS Medical Directors) Clinical Area Airway Element ETT*/ King Tube Airway *, ** ETCO2 *,** Breathing Pulmonary Edema ** NTG/CPAP ** AIRWAY, BREATHING, CIRCULATION QI Quality / Indicator Key Findings / Performance Measures Status Indicator Values % success*, SKL-1 King/ETT ratio % pts with advanced airways receiving ETCO2 monitoring *,**, SKL-2 % receiving NTG,CPAP CPAP Active, Core Measure Active, Core Measure Acitve ETT is a relatively infrequent skill Between 3/9/15 and 3/9/16, 53% of 827 accredited paramedics did not perform ETT 2015 King Tube Success Rate 90.8% 2015 ETT (< 1 attempt) First Pass Success Rate 54.1% 2016 ETT Success (< 2 attempts) 71.96%, SKL-1 ETT/King tube ratio increasing intervention # ETT = 756 King Tube = %, SKL CPAP Analysis ~110 patients/month 51% female (avg 72 y.o.),49% male (avg. 70 y.o.) On average, patients have increased SPO2, decreased P, BP and RR 86% documented as "Improved" 12% "Unchanged 2% "Worse Literature Search NIV Metaanalysis Prehospital CPAP can reduce mortality and intubation rates compared to standard care, while the effectiveness of prehospital BiPAP is uncertain. Improvement (planned or in progress) Protocol emphasis on ETT as first line advanced airway in CA pts has reduced King Tube Intervention # Video Laryngoscopy trials by FFD/ACFD/BFD (no apparent change in ETT success rate) Tableau Reporting Analytics First Pass success rate Develop overall advanced airway success measure 2017 Protocol Update An Intubation attempt is defined as insertion of laryngoscope blade into patient s mouth Workflows in Zoll epcr Focused education Tableau Reporting Analytics epcr data collection improvements made Upgraded from Mercury Flow-Safe II to Mercury Flow-Safe II EZ (with attached nebulizer) Breathing Bronchospasm *,** Albuterol / Atrovent *,** % of Pts with Resp. Distress /Bronchospasm receiving Alb/Atr combo, RES-2 Active, Core Measure % RES-2, Page 27

28 Breathing Anaphylaxis Epi Active Cardiac Arrest *,** Cardiac Arrest ** Cardiac Arrest Cardiac Arrest ROSC / Survival to Discharge *.** Time to Defib ** CPR Res-Q-Pod % Survival to Hospital Discharge, CAR-4 Median time from PSAP first ring to defib Cardiac Compression Fraction (CCF) CC Rate Vent Rate Peri-Shock Pauses % of Pts receiving Res-Q- Pod (ITD) Mean time to Res-Q-Pod Active, Core Measure Proposed Limited - Code Stat Active, BFD- Zoll CPR Analytics Active Proposed Cardiac Arrest Sodium Bicarb Sodium Bicarb administrations Active % of pts with Death Determination in Field Cardiac Arrest Death in Field (Cardiac Arrest Transport Rate) Active Cardiac STEMI/ACS *,** Cardiac STEMI* CVA * 12 lead/asa*,** Time* Blood Glucose* % of Pts with CP-Suspected ACS Impression receiving ASA. ACS Q1/Q2, Avg. D2D (Door to Device) time (All STEMI Centers) % of D2D < 90 minutes EMS on scene time, 90 th percentile, ACS-3 E2D (EMS to Device) Time STEMI ALERT Analysis % of Pts with CVA/TIA Impression receiving Glucose Monitoring*, STR-2/CPSS Assess Active, Core Measure Active Active Active Proposed 2016 Witnessed VF/VT (non-trauma) Survival to Hospital Discharge, 33% 2016 All Rhythms (non-trauma) Survival to Hospital Discharge, 9.16%, CAR-4 For patients that received therapyspecific resuscitation bundle of care (ITD, Mechanical CPR, Therapeutic Hypothermia), there was a 77% increase in CPC scores 2 among surviving patients with OHCA, from 4.7% to 8.3% (p<0.001) Limited data available 70% After 2017 update training, Sodium Bicarb administrations were reduced Cardiac Arrest Transport Rate reduced from 68% (2012) to 60% (2016) %, ACS mins, mins %, % mins 2016, mins, ACS STEMI ALERT Analysis o Sensitivity 91.5% o Specificity 98.8% o PPV 40% o NPV 97.7% Develop QI Indicator Perform Audit 2016 Epinephrine Adult IM dose modified from 0.3 mg to 0.3 mg- 0.5 mg ITD implemented in 2009 Lucas Implemented System Wide in 2011 Field Policies updated to current AHA guidelines Field re-education in 2015 policy update video uploading data to CARES In hospital TH screening criteria requires standardization Improved Cardiac Receiving Facility Data Collection Expand Code Stat BFD implementing Zoll CPR Performance Reviews epcr data collection improvements Cardiac Arrest data and audit indicated Sodium Bicarb was be administered when not indicated prior to 2017 Annual Policy Update Training Death in Field Policy updated Discontinuation of CPR extended from 20 to 30 minutes Tableau Reporting Analytics Improve ECG Transmission Process Expand CPR Analytics Develop E2D time measure Improved STEMI Center Data Collection Active, Core Measure %, STR-2 Daily monitoring in Tableau Page 28

29 CVA * Clinical Area Pain Management* Time* Element Pain Management * Avg. D2D time (All Stroke Centers) % of D2D < 60 mins. EMS On Scene Time, 90 th Percentile*, STR-3 E2D Time Quality / Performance Measures % of pts receiving Fentanyl when pain >7, PAI-1 Active Active Active Proposed PAIN MANAGEMENT QI Indicator Status Active mins ~41 mins % % mins, STR mins, STR-3 Key Findings / Indicator Values 2016, 22.42%, PAI-1 Fentanyl admins declining since 2015 Root Cause Analysis Opioid Crisis Awareness Reverse Distribution process complexities with increased documentation demands Training emphasis on providing least invasive to most invasive pain management tx Improved Stroke Center Data Collection Improved Stroke Center Processes including telecommunication between neurologist and patients at Kaiser facilities Education regarding transport of family member and obtaining phone #s of Improvement (planned or in progress) Fentanyl replaced Morphine in 2014 policy Pain Scale documentation required on all patients in 2014 Pain Management Pain Scale Pain Scale, VS pre/post Fentanyl administration Active 2015 Pain Management Analysis More patients are being treated for pain with opiates after the introduction of fentanyl Among patients with severe pain (pain score of 7-10), approximately 24% of them receive opiates. Most receive other measures (Splinting, ice, etc.) or it is not considered clinically appropriate. The intranasal route for fentanyl is rarely used. Fentanyl has a modest improvement in decreasing pain as compared to morphine. The complication rate is similar between fentanyl and morphine. Continued Monitoring/Analysis Ketamine trial discussed Page 29

30 Clinical Area Burns Trauma Trauma Trauma* Trauma*, ** Trauma ** Clinical Area Element IV Fluid Spinal Immobilization IV Fluid TXA Time* Trauma ** Quality / Performance Measures Amount of fluid critical burn pts receive #/% of Pts receiving spine motion restriction interventions % of pts/volume of IV fluid received when BP < 90 TXA Data Time intervals, Start with total time, time of incident to trauma center arrival On Scene Time 90 th %, TRA-1 Pts with ISS > 15 to trauma center ** Pts meeting critical trauma criteria to tc* TRA-2 BURNS, TRAUMA QI Indicator Status Active Active Proposed Active Proposed Active Proposed Key Findings / Indicator Values Burn patient fluid admin reduced an avg. of 59% after 2014 Alfred protocol fluid formula Implementation Long Backboard intervention continues to significantly decline since 2013 SMR policy implementation Sep July admins 2017 to August 8, 24 admins mins, TRA %, TRA-2 Improvement (planned or in progress) Alfred Formula introduced Parkland Formula (more fluid restrictive) replaced Alfred Formula Assess Parkland Formula impact on fluid administration Spine Motion Restriction Policy Implemented Vacuum Mattresses required on all first responder apparatus and transport provider ambulances TXA Policy implemented Jan TXA Trail Study with ICEMA TXA re-education late 2016 Reassess core measure data collection methodology Develop measure Trauma * Active Pts > 65 with ISS > 21 to trauma center ** Proposed Proposed Element Status Seizure ** Versed ** Sepsis Clinical Area Assessment Sepsis Alerts Element Ntg, Fentanyl, Versed Quality / Performance Measures OTHER MEDICAL EMERGENCIES QI Indicator Status Key Findings / Indicator Values Improvement (planned or in progress) % of pts with status seizures receiving Versed Proposed Audit Status Seizures # of Sepsis Alerts Active Sepsis Alert monthly # % of pts with Impression of has seasonal variation 2018 Sepsis Policy Update Sepsis and Sepsis Alerts Sepsis Alert median o Modify fluid admin - 30ml/ml % of pts meeting SIRS #/month trend NS in pts with Septic Shock criteria that have Sepsis increasing o Monitor ETCO2 Alerts /mo. median Develop Sepsis Quality /mo. median Fluid administration Quality / Performance Measures % of pts receiving repeat VS IO GCS > 3, IO #/% of IO when GCS > 3 IV IV, Saline Lock, NS Drip % Success Per Attempt IV Fluid vs. SL use PROCEDURES QI Indicator Status Proposed Audited in 2013 Active Key Findings / Indicator Values Audit revealed appropriate performance in both cardiac arrest and noncardiac arrest pts 82% success per attempt SL use increased while NS drip decreased Improvement (planned or in progress) 2018 IO Policy Update Add Humeral IO site Policy Update emphasized saline lock use Page 30

31 Sedation Clinical Area Versed pt responses, VS Proposed Assess adverse effect of sedation Element Quality / Performance Measures OPERATIONS QI Indicator Status Aircraft Transports Transport # Active Call Response * Continuity of Patient Care Data Compliance Dispatch Dispatch Dispatch Patient Satisfaction Transport Response Time * Ambulance Patient Offload Time (APOT) LP-15 data MPDS Response Time Compliance* (TCR to On Scene Arrival) Offload times o Ambulance arrival time at facility to in service time (Active) o APOT Arrival to TOC (by nurse signature at TOC) % of 12 lead, all ECG and CPR uploads from LP-15 to Zoll epcr and Code Stat Time response analysis Critical intervention analysis for determinants EMD compliance/correct categorization Active Active Active Active Active Key Findings / Indicator Values Launches 59 Transports Launches 21 Transports Monitor P+ response compliance has real time dashboard monitoring in First Watch All provider s response times are compliant with contractual requirements Median ambulance available time reduced min min 90 th Percentile APOT reduced Jan min July min 5-10% Current upload process using cables is cumbersome See ALCO EMS Blog /blog/ Dispatch Time Increments Time response analysis Proposed PSAP data is unavailable % of callers receiving proper pre-arrival instructions (ASA, CPR etc..) Proposed PSAP data is unavailable Improvement (planned or in progress) P+ has ongoing ambulance flexible deployment analysis Reassess core measure data collection methodology Measure from first ring time at PSAP APOT Data analysis IAW EMSA guidelines Real-time monitoring of hospital wait times Monthly data reporting to hospitals Data reporting to EMSA Engagement of EMS and hospital leadership and care providers in APOT improvement Upload trial of cardiac arrest pt data to CodeStat in progress Investigating wireless uploads P+ implementing monitor uploads Time Sensitive Intervention analysis tied to MPDS determinants to determine dispatch priority 27B response priority changed to post intervention analysis 6E analysis and MPDS Guideline changes Develop QI indicator for PSAP first ring time to first EMS response time ACRECC time interval analysis in progress Develop QI indicator for PSAP first ring time to first EMS response time Audit pre-arrival instructions Pre-Arrival Instructions Time Pain Discomfort Active Paramedics Plus is surveying patients Transport Rate Transport Rate* ROS Rate ROC Rate Active Proposed Proposed 66% epcr ROC/ROS data entry simplified for better data collection Page 31

32 Process, Data and Quality Indicator Analysis DATA COMMUNICATION -- CHARTS The use of charts is essential in the analysis of processes, data and quality indicators. While many different types of charts exist, the following charts provide the best process analysis. These charts are also easy to create and use. CONTROL CHARTS measure process improvement. Process Improvement = Quality Improvement Our current processes are perfectly designed to produce the results we are getting. Davis Balestracci All VF/VT Year Survival If given two different numbers, one will be bigger than the other. However, if given a series of numbers over a period of time and then plotting the dots, a picture of a process starts to emerge. All data has a time component of some sort. While many charts analyze process improvements, Control charts provide the best illustrations of process improvement over time. These charts are simple to create and easy to understand. Control charts in particular are a necessary tool all organizations must use to determine whether a process is improving or merely operating within some variation. A chart of numbers is just a chart of numbers. A Control Chart presents a picture of the story % % % % % % % % % % % % 45% 40% 35% 30% 25% 20% 15% All VF/VT Survival 10% Year Page 32

33 PARETO CHARTS / PIE CHARTS identify the most common contributing factors to a process. For example, regarding pediatric medication safety, first focusing efforts in analyzing and reducing errors in Morphine and Midazolam administrations makes sense. % of Total Pediatric Med. Administrations Albuterol 32.56% Morphine Sulfate 26.65% Midazolam 8.94% Diphenhydramine 8.05% Ipratropium 5.19% Zofran 3.76% Activated Charcoal 3.22% Epinephrine 1 to % Adenosine 1.79% NS Fluid Bolus 1.61% Oxygen 1.07% Aspirin 0.89% Naloxone 0.89% Atropine 0.72% Glucose Paste 0.72% Epinephrine 1 to % Nitroglycerine 0.36% Amiodarone 0.18% Dextrose 25% 0.18% Saline for Injection 0.18% TOTAL % Pareto Column Chart of Pediatric Drug Administrations 1/1/11 to 9/13/11 Page 33